Failure to Notify Physician and Responsible Party of Missed Lab Orders
Penalty
Summary
The facility failed to notify the physician and the resident's responsible party when laboratory tests ordered for a resident were not completed as directed. The resident, who had diagnoses including vascular dementia, cerebral infarction, and a history of TIA, was severely cognitively impaired and receiving Eliquis, a blood thinner. A pharmacy review noted that the resident's renal function might require a dosage adjustment, prompting the physician to order a complete metabolic panel, complete blood count, and renal function panel. However, these labs were not completed, and there was no documentation in the medical record explaining the missed tests or indicating that the physician or responsible party had been informed. Further investigation revealed that the lab technician attempted to collect the blood sample, but the resident was combative and refused, and no qualified personnel were available to assist. The lab requisition was left incomplete, and the floor nurse was not made aware that the labs were not obtained, resulting in a lack of follow-up or documentation. The facility's policy required notification of the physician and responsible party in such circumstances, but this was not done, constituting a failure to follow established procedures for notification of changes affecting the resident.